Form 62a384-G - Natural Gas Property Tax Return - 2011 Page 2

62A384-G (1-11)

NATURAL GAS PROPERTY DIVISION OF INTEREST—OWNERSHIP SCHEDULE

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

Lease Number _______________________________

Lease Name ________________________________________

Page _______________

Social Security No. or

Decimal % (0.875)

Ownership Type

Owner Name

Owner Address

City

State

ZIP Code

FEIN

Ownership of Lease

(W,O,R)

INSTRUCTIONS: The producer/operator or agent thereof is required to report (1) the names, SSN/FEIN, and addresses of the working, royalty, and overriding interest owners associated with the property as of January 1; (2) the decimal

percentage of ownership for each owner; (3) the type of ownership designated by the letter “W,” “R,” or “O”; and, if applicable, (4) the annual net income (including delayed payments) per royalty or fee owner.

NOTE: If the producer/operator owns all interest (working and royalty) in the property, enter “1.00” under the heading Decimal % Ownership and an “A” under Ownership Type. The assessment will be based on the industry standard

of .875 working and .125 royalty. Tax bills will be prepared according to this ownership schedule. Complete the schedule to reflect the desired billing.